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San Join County Environmental Health Dertment <br /> GREEN FORM <br /> DATE MASTER FILE((((RECORD INFORMATION "MFR" <br /> SHA-VA M EO Y OWNER ID# I { / <br /> CASE 45t�0`3�� UNIT <br /> �� <br /> a / OWNER FILE <br /> CHECK/F OWNER CURRENTLYON F2EWITN EHD ❑ <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION.' <br /> PROPERTY OWNER NAME A' I� PHONE <br /> Flrsf Mf Lost <br /> mal O r TAXID# <br /> BUSINESS NAME ,p�Ar7/'TI u <br /> 1�y11 yb D�• .���/ / T<jE��iN6 31( DRIVER's LICENSE Al <br /> Owner Homs Address /J c� ,� <br /> N • STATE ZIP % J(�(/,(� <br /> city <br /> Owner Mailing Address T/1J1' 1 �j6 <br /> State Zip y � <br /> Mailing Address City 5 //T6N <br /> PARTNERSHIP El FED AGENCY OTHER❑ <br /> P0CONPOflAT10N❑ p� INDIVIDUAL❑ J y /- <br /> PRd . ��0�0 !/ /170 FACILITYFILE �191n 117 I� )Qe-G s/rF/y7%T !J(%OI✓ <br /> FACILITY ID# 1101 CROSS REF ID AccoUNTID# 37CDLf.� INV# <br /> COMPLETETHEFOOL`ILOW/N1GoBUSINESS I FACILITY/SITE/NFORMATION: d T <br /> IS this a NEW BUSIOe58 LOCATION not preVlOUSIy regulated by the ENVIRONMENTAL HEALTH <br /> Yes ❑ N0 <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? �rJ YES NO ❑ <br /> SUStNE88/FACILITY/SITENAME �.!-hC��� <�j V �C.af Wim-'{ `-O' ',u^r O ItS't�- e-10 <br /> SITEADDRESS �..f SUITE# aU81NE88 PN E <br /> ✓ r �111_MA¢-Aa IvTH E✓L l�laG-�R- ! -0" 00 <br /> Cm s6 ' L( STATE I �/{ ZIP <br /> c,",j I.Yr <br /> BOARD OF SUPERVISOR DISTRICT <br /> LOCATION CODE REY1 KEY2 <br /> Attention:or Care Of(apf/ana/J J <br /> Mailing Address ffDIfFEREA?hom Facility dress 3� D Q t ass,/ G err' <br /> V C.. <br /> ( / � STATE / ,/f ZIP <br /> Mailing Address City �Lib 0611'a 8 V l4. (_.•'? '1 ✓ tl <br /> isle CODE APN# ��,a3pQ 3 COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaoility Operator identifiedabove. <br /> I f (`, f Attention:OfCOre Of (OPBORa/ <br /> BUSINESS NAME <br /> 'IfT/""i C:G L,y1 tl-fdt/ l _ C' (/ 1 / q / L�(' ,l <br /> y t/J J.F'�• ! Q PHONE 1 �b� O� i �Uyo U <br /> Meiling Aadreee �o( ? •( D✓t✓ {F- <br /> 'f.J C" J o�JJ STATE L y(y ZIP <br /> CI <br /> N <br /> AamynTAauREas for fees and charges <br /> OWNER FACILITYIBUSINESS THIRD PARTY BILLIN <br /> Operator,or Authorized A#ent of this Budnesx,end a Rnnr FEES, <br /> BILLING AND COMPLIANCE ACXNOwLEDcmgnT: 1,the undersigned Applicant certify <br /> fy that i am the Owner,Op <br /> FENALTlav,ENF08CE11F1WCRARGES and/or Nm'RGYCNARGE.s associated with this operation will be billed m me of the address identified above as the ACYOrTADnRFS'S'for this sits 1 also ttrrify Uel all <br /> information provided on this application u true and correct;and that all regulated activities operator,or will be pent omf the ed naccordance aced at the above fadSryhHe address,i hereby eulhorixe t Mea nance Codes And/or <br /> Standards and STATE Andfor FEDERAL Lawn anti Regulations. As the undersigned owner,opo g property <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon in it is available and at the same time it n <br /> provided to me or my represenlative. <br /> APPLICANT NAME ,�( ^ ' �R JP <br /> �/f7 /'"a'- SIGNATURE <br /> TITLE �.Q�./t L.f l5'fJfl Iti 41 S t <br /> Approved BY Data <br /> Accountl�OtRce Praceseing Completed By Date <br /> 29-002 April 25,2007 �r,tAt/ //IIl�1 j �6b <br /> P-e— I <br />